Pearl City Post Acute

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow proper food handling and storage practices in accordance with professional standards for food service safety. Specifically, the facility failed to keep bulk food items off the floor in the storage room and did not label two containers of food brought in by family/visitors in one of three unit refrigerators sampled. Unsafe and/or unsanitary food handling and storage practices have the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness as a result of their compromised health status.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the resident's court-appointed guardian was informed, in advance, of the risks, benefits, and available treatment alternatives related to psychotropic medications prescribed by the physician for one of five residents (Resident (R) 74) reviewed for unnecessary medications. This puts R74 at risk of receiving unnecessary psychotropic medications without informed consent. Findings Include:R74 was admitted to the facility on [DATE] with diagnoses of unspecified mood (affective) disorder, insomnia, and history of falling. On 10/04/24, R74 was deemed incapacitated and a court-appointed guardian with unlimited authority was established. Review of R74's physician orders document R74 was receiving the following psychotropic medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, support, and honor the preferences for one of one resident (Resident (R)47) sampled for Choices. The facility failed to honor R47's preference to be assisted outside the facility for fresh air wearing the hospital gown. As a result of this deficient practice, R47 did not have his needs met and was placed at risk of not attaining his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations and interview, the facility failed to provide a clean, comfortable and homelike environment, as evidenced by a heavy buildup of dust on the fans for Resident (R)83 and R109. This deficient practice could affect all residents in the facility if their environment is not kept clean, putting them at risk for increased adverse health conditions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that two of four sampled residents (Resident (R)3, and R8) were free from physical restraints. Specifically, the facility failed to document when the restraints were applied and released. As a result of this deficient practice, R3 and R8's rights were violated, and were placed at risk of avoidable injury and/or a decline in their psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic medication was necessary to treat a specific, diagnosed, and documented condition and an as needed (PRN) antipsychotic medication order was limited to 14 days without exception for two of five residents (Resident (R)74 and R13) reviewed for unnecessary medications. This puts residents at risk for unnecessary use of psychotropic medications, including use as chemical restraints, which may lead to over-sedation, confusion, falls, and decreased quality of life, and violates their right to receive medications only when clinically indicated. Findings Include:1) R74 was admitted to the facility on [DATE] with diagnoses of unspecified mood (affective) disorder, insomnia, and history of falling. [...]

Inspectors wroteBased on record review and interviews, the facility failed to report an injury of unknown origin that resulted in serious bodily injury for one of one resident (Resident (R)63) reviewed for abuse. The facility did not ensure that the injury was reported immediately, but no later than two hours after identification, to the State Survey Agency (SA) and Adult Protective Services (APS). Specifically, while providing care, a staff member observed that R63's contracted right shoulder and elbow unusually loose. Subsequent X-rays confirmed a fracture of the right humerus (upper arm bone). Despite this finding, the facility did not report the injury within the required timeframe. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize and put preventive measures in place to prevent the potential development of pressure injury for one of one resident (Resident (R)2) utilizing a nasal cannula to receive oxygen. This deficient practice put all residents that utilize a nasal cannula at risk for potential development of medical device related pressure injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff wear applicable personal protective equipment (PPE) when providing care to two of 11 residents on Transmission Based Precautions (TBP). This deficient practice placed the residents at risk for the potential spread of preventable infections and communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and promote the rights for two of 25 residents sampled (Resident (R) 28 and R82) by ensuring that she was treated with respect and dignity. This deficient practice has the potential to affect all residents in the facility. Findings Include: R28 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of the following but not limited to Hemiplegia and Hemiparesis (weakness) following non-traumatic Intracerebral Hemorrhage (stroke) affecting the left side. A review of her Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 02/20/25 noted R28 had severe cognitive impairment, and the Brief Interview for Mental Status (BIMS) couldn't be conducted. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's care plan was revised to include and implement interventions to prevent and minimize conflicts between residents for one of two residents (Resident (R) 69) sampled for mood and behavior. R69 displayed aggressive behavior toward selective residents when eye contact is made. This puts residents at risk of untoward behavior. Findings Include: On 05/20/25 at 09:52 AM, observed a resident, R83, from a distance in the activity room upset and yelling toward another resident, later identified as R69. R69 was observed to be sitting in the activity room not responding and far away from R83. Staff was able to redirect R83 and did not appear upset anymore. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assist two dependent resident's (R) 66 and R75 of three residents in the sample, in the care necessary to achieve basic hygiene. The deficient practice may affect all the residents who are dependent on the staff on the unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate treatment and services to prevent potential complications of enteral tube-feeding (TF) for one of one resident (Resident (R) 19) sampled for TF. The TF formula and TF flush bag was not labeled with a date which would indicate that the formula and flush bag were changed every 48 hours. As a result of this deficient practice, the facility placed residents who are on enteral nutrition at risk for avoidable infections and complications. Findings Include: On 05/20/25 at 09:33 AM, observed R19's TF formula with approximately 100 milliliters (mL) left and TF flush bag with a label indicating it belonged to R19, but the date was left blank. On 05/22/25 at 02:18 PM, an interview with Director of Nursing (DON) was done. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure one Resident (R) 68 of five residents in the sample, was free from unnecessary medication by providing R68 with an anti-anxiety medication as needed for greater than 14 days, and the physician did not provide the rationale for continuing the medication as ordered. The deficient practice may affect the residents who are receiving psychotropic medications.

Inspectors wroteBased on observation and interviews, the facility failed to dispose of an intravenous (IV) medication vial labeled for single use. As a result of this deficient practice, residents who require IV fluids and medications were placed at risk of receiving expired fluids. This deficient practice has the potential to affect any patient taking IV medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food handling and storage practices in accordance with professional standards for food service safety. Unsafe and/or unsanitary food handling and storage practices have the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for foodborne illness.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure shared medical devices were properly disinfected after use. Specifically, the facility did not use the appropriate disinfectant to wipe the shared blood glucose meter (device used to measure blood sugar levels). The facility also failed to ensure proper aseptic technique was used to prevent the transmission of communicable diseases and infections when initiating Intravenous (IV) medication for Resident (R)82. The deficient practices have the potential to expose the residents requiring blood glucose testing and IV medications to diseases-causing pathogens.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure that one resident (R) 25 of three in the sample received care and services to prevent a urinary tract infection (UTI). The resident's indwelling foley catheter was not removed as ordered upon admission to the facility until [DATE] and the resident developed a UTI. The Resident declined and was hospitalized on [DATE] for a serious illness.

Inspectors wroteBased on interview, record review and document review, the facility failed to Recognize, evaluate, and address the needs of one resident of three in the sample who was at risk for adequate hydration and nutrition status. This deficient practice may have resulted in decline, weight loss, and an unplanned hospitalization with severe illness.

Inspectors wroteBased on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Minimum Data Set (MDS), the facility in-accurately coded Restraint use for Resident (R)33 of three residents sampled. As a result of this deficiency, the facility put R33 at risk for further RAI, MDS inaccuracy.

Inspectors wroteBased on interviews and record reviews, the facility failed to include one of the sampled resident's (Resident (R) 89) representatives in developing and implementing a comprehensive, person-centered care plan. Findings Include: R89 is a [AGE] year-old male admitted to the facility on [DATE]. R89 has a medical history that includes, but not limited to, nontraumatic intracranial hemorrhage, chronic respiratory failure, and persistent vegetative state. Interview was conducted with R89's family representative on 04/22/24 at 12:04 PM in R89's room. R89's family representative stated that she does not remember having a meeting with the facility's Interdisciplinary Team (IDT) since R89's admission to the facility. She also added that it would be great if they had a meeting to discuss his plan of care. Interview and record review was conducted on 04/23/24 at 01:03 PM with Social Worker (SW). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure one of the 24 residents (Resident (R) 220) in the sample received care and treatment in accordance with professional standards of practice. The intravenous (IV) solution bag and lines were being used past the specified discard date. This deficient practice has the potential to affect all residents at the facility that require IV therapy.

Inspectors wroteBased on observation, staff interview and review of manufacturer product description, the facility failed to identify a potential electrical accident hazard for one Resident (R)42 of eight residents reviewed. As a result of this deficient practice, the facility put the safety and well-being of all the residents as well as the public at risk for accident hazards.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that one of the residents (Resident (R) 46) in the sample that had a urinary catheter received the appropriate treatment and services to prevent urinary tract infections. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections and has the potential to affect all residents with a urinary catheter.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to store food items under sanitary conditions. This failed practice could place one resident at risk for food-borne illness. Findings Include: Observation was conducted on 04/22/24 at 09:45 AM on the fourth-floor recreation room. The recreation room housed a refrigerator for residents' food items. The refrigerator contained five containers filled with a resident's food items brought in by his/her visitors. The five containers all had a sticker labeled, Use by date, 04/19/24. Interview was conducted with Registered Nurse (RN) 10. RN10 was shown the five food items belonging to a resident. RN10 stated that it should have been thrown away on 04/19/24. Interview was conducted with the Food Service Manager (FSM) on 04/23/24 at 10:55 AM. [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for one of the 24 sampled residents (Resident (R) 46) in accordance with accepted professional standards and practices. This deficient practice has the potential to affect medical care provided to all the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to Resident (R) 7 was free of any significant medication errors.

Inspectors wroteBased on observation, interview and review of the facility's policy and procedures the facility failed to ensure measures to prevent the spread and transmission of communicable diseases were followed. Facility staff did not perform hand hygiene before donning gloves and did not clean the floors with a sanitizing solution.